The physician ordered several tests: An EKG, CBC, CMP, magnesium, CK MB, and troponin.
The EKG was completed and is shown below. The court used a copy of the EKG that was unfortunately very poor quality. In order to make this case easier to understand for readers, MedMalReviewer has digitally enhanced the EKG. The enhanced copy is easier to read but has admittedly lost some fidelity. The enhanced copy is shown first, followed by the court scan of the original.
The automated EKG interpretation reads “Sinus rhythm with sinus arrhythmia, right atrial enlargement, rightward axis, possible anterior infarct, age undetermined, abnormal ECG”.
The doctor ordered several medications during the patient’s stay. She was given nitroglycerin without any change. Following this, 500mL normal saline was given, with a repeat BP 124/87. She was then given Toradol 30mg IV with a documented response “states maybe a little better”.
The lab results are shown here:
| CBC | Result | Normal range |
|---|---|---|
| WBC | 14.4 (H) | 4.8 - 10.8 |
| RBC | 3.99 (L) | 4.2 - 5.4 |
| Hemoglobin | 13.2 | 12.0 - 16.0 |
| Hematocrit | 39.5 | 37.0 - 47.0 |
| MCV | 98.9 | 81.0 - 99.0 |
| MCH | 33.0 (H) | 27.0 - 31.0 |
| MCHC | 33.4 | 32.0 - 36.0 |
| RDW | 13.4 | 11.5 - 15.5 |
| Platelets | 291 | 130 - 400 |
| Mean Platelet Volume | 7.3 (L) | 7.4 - 10.4 |
| Neutrophil % | 84.8 (H) | 50.0 - 75.0 |
| Lymphocyte % | 10.1 (L) | 20.5 - 45.5 |
| Monocyte % | 4.0 (L) | 5.5 - 11.7 |
| Eosinophil % | 0.9 | 0.9 - 2.9 |
| Basophil % | 0.2 | 0.2 - 1.0 |
| Neutrophil Absolute # | 12.2 (H) | 2.2 - 4.8 |
| Lymphocyte Absolute # | 1.5 | 1.3 - 2.9 |
| Monocyte Absolute # | 0.6 | 0.3 - 0.8 |
| Eosinophil Absolute # | 0.1 | 0.0 - 0.2 |
| Basophil Absolute # | 0.0 | 0.0 - 0.1 |
| CMP | ||
| Glucose | 118 (H) | 70 - 110 |
| BUN | 16 | 7 - 18 |
| Creatinine | 0.9 | 0.6 - 1.3 |
| BUN/Creat | 17.8 | 6.0 - 20.0 |
| GFR | 64 | >60 |
| Sodium | 139 | 136 - 145 |
| Potassium | 3.3 (L) | 3.5 - 5.1 |
| Chloride | 102 | 98 - 107 |
| Bicarbonate | 30.1 | 21.0 - 32.0 |
| Anion Gap | 10.2 | 10 - 18 |
| Total Protein | 6.8 | 6.4 - 8.2 |
| Albumin Serum | 3.3 (L) | 3.4 - 5.0 |
| Globulin | 3.5 | 2.0 - 3.9 |
| Albumin/globulin ratio | 0.9 (L) | 1.0 - 2.4 |
| Calcium | 8.7 | 8.5 - 10.1 |
| Osmolality Calculated | 280 | 275 - 295 |
| Bilirubin Total | 0.2 | 0.00 - 1.00 |
| Alkaline Phosphatase | 103 | 50 - 136 |
| AST/SGOT | 18 | 15 - 37 |
| ALT/SGPT | 21 (L) | 30 - 65 |
| Magnesium | 1.8 | 1.8 - 2.4 |
| Cardiac Panel | ||
| CK MB | 1.9 | 0.0 - 3.6 |
| Troponin I | 0.06 | 0.00 - 0.10 |
After reviewing these lab tests, what is the correct next step?
Should the patient undergo further testing?
Can she be discharged or should she be admitted?
The final part of the physician’s documentation is shown below. He noted the normal labs including the troponin. The EKG is marked as normal sinus rhythm. He documented that she has improved, and that he counseled her in regards to the need for follow-up. She was discharged from the ED.
Continue to the next page to see what happens next.
